Hospitalized patients present a particularly difficult challenge to manage from a patient safety perspective. Some of the increased risks for hospitalized patients are:
- Organ dysfunction during acute illness, leading to alterations in metabolism that may affect medication clearance.
- Variation in hospital practice of holding versus administering oral hypoglycemic medications.
- Incomplete or erroneous medication reconciliation, placing the patient at risk for omission errors or dosing/scheduling errors.
- Transitioning between diets and “NPO” (nothing by mouth) status, if hypoglycemic medications are not held appropriately when food is not delivered.
- Fluctuating hospital formularies, often requiring medication substitutions despite the hospital staff’s uncertainty on dosing equivalents as well as confusion on the part of the patient and/or caregiver due to lack of familiarity.
- New diabetic medications on the market, which make it difficult for non-medicine physicians, such as surgeons, to stay current on the properties of the medications, including half-lives and elimination pathways. This is especially important with insulins, as they are more likely to be given in the acute setting.
- Surgery-related diet transitions and physiologic changes that demand expert management of hypoglycemic agents.
To minimize the risk to patients, hospitals should develop a focus on diabetes as part of their quality oversight and maintenance activities. The Joint Commission provides hospitals with guidance and certification for inpatient diabetes management. The requirements for certification can serve as a guide to all hospitals on how to improve care and decrease risk for patients with diabetes. Hospitals that seek to acquire certification must have:
- Specific staff education requirements
- Written blood glucose monitoring protocols
- Plans for the treatment of hypoglycemia and hyperglycemia
- Data collection on incidences of hypoglycemia
- Patient education on self-management of diabetes
- An identified program champion or program champion team
Professional societies are also now involved in creating hospital systems change to improve diabetes care. For example, the Society of Hospital Medicine has created an online resource that provides multiple tools, guidelines, and ideas in one easily accessible location for hospitals.
Medication errors are particularly common in the hospital setting.
The Institute for Safe Medication Practices (ISMP) is an independent nonprofit organization whose mission is to improve medication safety. The ISMP maintains a list of high-alert medications for acute care (PDF, 148 KB)and ambulatory settings (PDF, 94 KB). Oral hypoglycemic agents and insulin appear on both of these lists. According to the ISMP, agents on these lists may requires specific risk-reduction strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about them; limiting access to high-alert medications; using auxiliary labels and automated alerts; and employing redundancies such as automated or independent double-checks when necessary.
Recently the ISMP has partnered with DiabetesInControl.com to focus on safety for patients with diabetes. They developed a series of articles that focus on patient safety topics and medication management.
Infectious agents can be transmitted to patients due to several key diabetic care elements, including fingerstick/lancet use, glucometer use, and insulin pen and vial use. Infectious agents, particularly viruses such as hepatitis B, can be transmitted through either direct or indirect contact with these devices. The Centers for Disease Control and Prevention has created risk mitigation strategies for preventing infections during blood glucose monitoring and insulin administration and issued a clinical reminder of the risk for transmitting bloodborne pathogens from using fingerstick devices on more than one person.